Transition to Community Referral 

Mississippi Access to Care (MAC) Centers provide TCR services for individuals to transition from nursing facilities to community living in all 82 counties within the state.

Procedures

Nursing facility (NF) staff will create the Transition to Community Referral (TCR) in the electronic Long-Term Services and Supports (eLTSS) system within 10 days of receiving a “yes” answer from a resident to question Q0500B on the Minimum Data Set (MDS). After referral is submitted by NF, the referral will be available for Mississippi Access to Care (MAC) Center staff to review in eLTSS.

The Mississippi Department of Human Services (MDHS) Program Specialist for MAC Center will check eLTSS daily for new referrals. The Program Specialist will identify the county of transition for each referral and send a message in eLTSS to the appropriate MAC Center alerting them of the new referral.

MAC Center staff will review the TCR form for services needed; identify and select the appropriate waiver(s); add the tentative discharge date (if known) to the form; and submit. This process will be completed within 5 business days.

After MAC Staff completes and submits their portion of the referral form, it will be available to the Waiver Case Management Agency (CMA). The CMA will contact the individual or their representative with information about services and/or resources in the community. The CMA staff will document the outcomes of their communications with the person or representative regarding Home and Community Based Services (HCBS).